Job summary
ThepostholderwillbeakeymemberoftheIntegratedNeighbourhood teams,inwhichyouwillcase manage complex patient who are homeless or at risk of becoming homeless. They will beresponsibleforthesmoothoperationofco-ordinatingcomplexmulti-disciplinaryteammeetingsandworkingasanautonomouspractitionerwithintheirspecialtyarea.
Thepostholderwillbe thelinkbetweenprimarycare and keycoreproviderserviceswithinthelocality.Youwillbeworkingwith GeneralPractitioners,Practicestaff,CommunityservicesfromELHT,AdvancedNursePractitioner(s)(whereinpost),specialistservicesandpartnerprofessionals and agenciesfromwithinandbeyondtheINT to build high impact partnerships and drive transformation.
Youwillbedevelopingandpromoteacasemanagementapproachtocareandpromotingthebenefitsofcoordinated,holisticcareforpatientsandfacilitatingthisprocessthroughthefacilitation,organisationandplanningofmulti-disciplinaryteammeetings.Youwillneedto be appropriately trainedtounderstandholisticcareplanninganddeliver quality patientcentredservice.
Main duties of the job
The post holder provides a case management approach for patient with complex need in the community who are experiencing homelessness or at risk of becoming homeless. This post holder will work with the Integrated Neighbourhood team. The post holder will work in the community, assessing patients in the own environments, to provide the best possible patient outcomes. They will ensure collaborative working across divisions, with General Practitioners, partner professionals and agencies to secure care in the community sooner with positive outcomes for patients with complex needs.
The post holder will provide the leadership, direction, for effective and efficient service delivery and will support the manger in the delivery of strategic and organisational initiatives and priorities, and reducing avoidable bed days/admissions, whilst maintaining high standards of clinical practice and professional conduct.
Car driver with access to a vehicle is essential
Please refer to job description for full details.
About us
Established in 2003, East Lancashire Hospitals NHS Trust (ELHT) is a large integrated health care organisation providing high quality acute and community healthcare for the people of East Lancashire and Blackburn with Darwen.
The organisation puts safety and quality at the heart of everything we do, invests in and develops its workforce, works with key stakeholders to develop effective partnerships and encourages innovation and pathway reform to deliver best practice.
We employ over 8,000 staff, many of whom are internationally renowned and have won awards for their work and achievements.
Job description
Job responsibilities
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WorkwithinthemodeloftheINT,providingleadershipandsupportonthemattersrelatingtoadmission avoidanceandthetransferofcare.
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Workcloselywithallservices. Integratingworkingpracticestostreamline processes,shareknowledge;andbenefit patientexperience and outcomes.
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Contributetothedevelopmentandprovisionofaresponsiveandproactiveneighbourhoodlocality basedapproachtothe preventionof avoidablehospitaladmissions. Toidentifyandmobiliseinterventionstoreduceriskandmaintainpatientsinthe community and supporting them find appropriate accommodation working alongside our housing colleagues and partner services.
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Actasaresourceandfirstpointofcontactfor clinicians. To help improvecommunicationandconsistencyofcareforpatientsreceivinganumberofdifferentservicesandorrequiringadditionalsupporttominimiseriskofadmissionasidentifiedby riskprofiling,casefindingandlocalintelligence.
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Ensurethecoordination,planninganddeliveryofregularmultidisciplinaryteammeetingshappens.
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Chaircomplexmultidisciplinarymeetings,ensuringalldocumentationisrecordedregardingoutcomes,facilitatetheprocessofagreeingacasemanagerandcasemanagementapproach.
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Supportcasemanagersinsettingupofmeetingsandliaisingwithappropriateservicesandthepatientandcarers where relevant.
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Toutiliseclinicalexpertisetofacilitatecareclosertohomeandpromotingaholistic,multiagencyresponsetocasemanagementtomeetthepatientsneeds.
9.Engageproactivelywithkeystakeholders(forexampleGeneralPractitioners,AdvancedPractitioners,theIntegratedNeighbourhoodTeams,specialistservices,SocialServices,independent/privatesectorproviders andICAT/IHSS) toidentifypatientswhorequiresupportiveinterventionandcasemanagementtopreventavoidablehospitaladmissionandenable safe quality of acre to thoseindividuals.
-
Tofollowtheprogressofthosepatientsidentifiedoncasemanagementregistersfromthelocalitieswhoareadmittedtoacutecareandsupportanearlytransfer to community once thepatientsconditionhasstabilised,liaisingwith hospital staff and membersoftheintegratedteamandkeypartnerstoreducetherisksassociatedwithtransferofcare.
-
Toassess,receiveandreviewdataregardingpatientswhoregularlyattend/areadmittedtoacutecare,liaisingwithpatients;andrelatives/carersasappropriate;theintegratedneighbourhoodteamandkeystakeholderstodevelopaholisticcasemanagementapproachtosupportindividualstoremainindependentandpreventavoidablereadmission.
-
Tobeinvolvedwithandsupportthedevelopmentandongoingmaintenanceofdatamanagementsystems.
-
Contributetothedevelopmentandimplementationofsystemsandprocessesthatensuretheneedsofdisadvantagedgroupsareidentifiedandprogressed.
-
Contribute to trainingand/ordevelopmentactivitieswithinandbeyondtheDivisiontoraiseawarenessofcommunityprovision,capacityandcapability.
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Activelypromoteafocusonself-care/managementtoreducerelianceonservicesandincreaselevelsofindependencewithinthepatientpopulation.
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Workincollaborationwiththeintegratedneighbourhoodteamtoprovideinformation,preparepatientsandtheirfamilies/carersforchangesinthepatientsconditionandactivelyencourageandsupportdecisionmakingandchoiceforendoflifecareincludingtheuseof fasttrackandCHCprocesses.
-
Prioritiseandmanageownworkloadtoensureresponsivecare/interventionsbystaffwiththelevelofskillandcompetencetomeetpatientneedandprovideadviceandsupporttoteammembersregardingthecare/managementplan.
-
Responsibilityfor the post holder toensurethesmoothrunningof theMDTmeetingsoccursandmeetsplannedobjectives.
-
Ensureownleadershipstylefacilitateseffectivecommunication,collaborationandmotivationofstaffandpartnerstopromoteanintegratedandholisticapproachtothemanagementoffuturecareforpatientsandcarers.
Job description
Job responsibilities
-
WorkwithinthemodeloftheINT,providingleadershipandsupportonthemattersrelatingtoadmission avoidanceandthetransferofcare.
-
Workcloselywithallservices. Integratingworkingpracticestostreamline processes,shareknowledge;andbenefit patientexperience and outcomes.
-
Contributetothedevelopmentandprovisionofaresponsiveandproactiveneighbourhoodlocality basedapproachtothe preventionof avoidablehospitaladmissions. Toidentifyandmobiliseinterventionstoreduceriskandmaintainpatientsinthe community and supporting them find appropriate accommodation working alongside our housing colleagues and partner services.
-
Actasaresourceandfirstpointofcontactfor clinicians. To help improvecommunicationandconsistencyofcareforpatientsreceivinganumberofdifferentservicesandorrequiringadditionalsupporttominimiseriskofadmissionasidentifiedby riskprofiling,casefindingandlocalintelligence.
-
Ensurethecoordination,planninganddeliveryofregularmultidisciplinaryteammeetingshappens.
-
Chaircomplexmultidisciplinarymeetings,ensuringalldocumentationisrecordedregardingoutcomes,facilitatetheprocessofagreeingacasemanagerandcasemanagementapproach.
-
Supportcasemanagersinsettingupofmeetingsandliaisingwithappropriateservicesandthepatientandcarers where relevant.
-
Toutiliseclinicalexpertisetofacilitatecareclosertohomeandpromotingaholistic,multiagencyresponsetocasemanagementtomeetthepatientsneeds.
9.Engageproactivelywithkeystakeholders(forexampleGeneralPractitioners,AdvancedPractitioners,theIntegratedNeighbourhoodTeams,specialistservices,SocialServices,independent/privatesectorproviders andICAT/IHSS) toidentifypatientswhorequiresupportiveinterventionandcasemanagementtopreventavoidablehospitaladmissionandenable safe quality of acre to thoseindividuals.
-
Tofollowtheprogressofthosepatientsidentifiedoncasemanagementregistersfromthelocalitieswhoareadmittedtoacutecareandsupportanearlytransfer to community once thepatientsconditionhasstabilised,liaisingwith hospital staff and membersoftheintegratedteamandkeypartnerstoreducetherisksassociatedwithtransferofcare.
-
Toassess,receiveandreviewdataregardingpatientswhoregularlyattend/areadmittedtoacutecare,liaisingwithpatients;andrelatives/carersasappropriate;theintegratedneighbourhoodteamandkeystakeholderstodevelopaholisticcasemanagementapproachtosupportindividualstoremainindependentandpreventavoidablereadmission.
-
Tobeinvolvedwithandsupportthedevelopmentandongoingmaintenanceofdatamanagementsystems.
-
Contributetothedevelopmentandimplementationofsystemsandprocessesthatensuretheneedsofdisadvantagedgroupsareidentifiedandprogressed.
-
Contribute to trainingand/ordevelopmentactivitieswithinandbeyondtheDivisiontoraiseawarenessofcommunityprovision,capacityandcapability.
-
Activelypromoteafocusonself-care/managementtoreducerelianceonservicesandincreaselevelsofindependencewithinthepatientpopulation.
-
Workincollaborationwiththeintegratedneighbourhoodteamtoprovideinformation,preparepatientsandtheirfamilies/carersforchangesinthepatientsconditionandactivelyencourageandsupportdecisionmakingandchoiceforendoflifecareincludingtheuseof fasttrackandCHCprocesses.
-
Prioritiseandmanageownworkloadtoensureresponsivecare/interventionsbystaffwiththelevelofskillandcompetencetomeetpatientneedandprovideadviceandsupporttoteammembersregardingthecare/managementplan.
-
Responsibilityfor the post holder toensurethesmoothrunningof theMDTmeetingsoccursandmeetsplannedobjectives.
-
Ensureownleadershipstylefacilitateseffectivecommunication,collaborationandmotivationofstaffandpartnerstopromoteanintegratedandholisticapproachtothemanagementoffuturecareforpatientsandcarers.
Person Specification
Person Spec
Essential
- RGN/ RMN/ HCPC registered therapist/ social worker
- Evidence of recent professional development
- Post registration experience
- Understanding of a case management approach
- Ability to demonstrate evidence of working holistically to deliver person centred care
- Understanding of self management and self care principles
- Community care legislation. Health and Social Care policy including Mental Capacity. Current developments in Integrated Neighborhood team (e.g. NHS 10 year plan)
- Up to date clinical knowledge. Including evidence based practice for long term conditions management.
Desirable
- Leadership qualifications
- Management Qualifications
- recent community experience or rehabilitation experience.
- Experience of being a case manager
- Knowledge of health promotion/education/hospital avoidance.
- Non-medical prescribing and/or clinical examination and/or clinical diagnostic CPD module
Person Specification
Person Spec
Essential
- RGN/ RMN/ HCPC registered therapist/ social worker
- Evidence of recent professional development
- Post registration experience
- Understanding of a case management approach
- Ability to demonstrate evidence of working holistically to deliver person centred care
- Understanding of self management and self care principles
- Community care legislation. Health and Social Care policy including Mental Capacity. Current developments in Integrated Neighborhood team (e.g. NHS 10 year plan)
- Up to date clinical knowledge. Including evidence based practice for long term conditions management.
Desirable
- Leadership qualifications
- Management Qualifications
- recent community experience or rehabilitation experience.
- Experience of being a case manager
- Knowledge of health promotion/education/hospital avoidance.
- Non-medical prescribing and/or clinical examination and/or clinical diagnostic CPD module
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).